Plné znění - 241/2006 Sb.

Questionnaire xxx xxx Assessment xx Xxxxxxxxxxxx xxx xxx Xxxxxxxxx of Xxxxxxxxx Xxxxxxx to Xxxxxxx of Xxxxxxxx Xxxx xxxxxxxx to Xxx No. 209/1997 Xxxx., xx the xxxxxxxxx xx fulancial xxxxxxx xx xxx xxxxxxx xx xxxxxxxx xxxx xxx xx xxxxxxxx xxxxxxx xxxxx xxxx, xx xxxxxxx

Xxxx Xxx/Xxxxx,

Xx apologise xxx xxxxxxxxx xxx xxxx xxxxxxxx xxxxxxxxx xx xxxx xxxxxxx xxxxxxxxx. Xxxxxxx, filling xx xxxx questionnaire xx xxxxxxxx for the xxxxx xxxxxxxxxx of xxxx xxxxxxxxxxx xxx xxx xxxxxxxxx xx xxxxxxxxx xxxxxxx xxxxxxxx xx Xxx no. 209/1997. Xxxxx xxx xxx xxxx cooperation; xx xx xxxxxx xxxxxxxxxxx.

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X. Xxxxxx xxxxxxx xxxx xx xxx xxxxxxxx xxxx of xxx applicant - x.x. the xxxxxx xx xxx criminal xxx who xxx xxxxxxxx xxxxxx harm, xx xxx survivor xx x xxxxxx xxx has died xx xxxxxxxxxxx of xxx xxxxxxxx act:

1. Xxxxxxx:

2. Given xxxx:

3. Xxxx xx xxxxx:

4. Xxxxxxxxx xxxxxxx:

5. Xxxx xxxxxxxx address (xxxxxx xx xxxxxx xxxx xxx permanent address, xxxx):

6. Phone Xxxxxx:

7. X-xxxx xxxxxxx:

8. Xxxxxxxxxxx:

XX. Xx xxx xxxxxxxxx xx represented xx xxxxxxx xxxxxx ("xxxxxxxxxxxxxx") xx xxx xxxxx xx xxxxxxxxx xxxxxxxxxxxxxx (xxx xxxxxxxx, a xxxxx xxxxx xxxxxxxxxxx xx xxx/xxx xxxxxx) xx xx xxx xxxxx of x xxxxx xx attorney, xxxxxx xxxx in xxx data of xxxx representative:

1. Xxxxxxx:

2. Xxxxx xxxx:

3. Xxxxxxxxx xx xxxxxxxxxx address:

If xxx xxxxxxxxxxxxxx xx xxxxxx xxx application xx xxxxxx xx xxx xxxxxxxxx, xxxxxx xxxx xxxxxx x xxxxxxxx xxxxxxxxxxx xxx/xxx xx represent xxx xxxxxxxxx - a xxxx xx a xxxxx of xxxxxxxx (xxx xxxxxxxxxxx representation) xx a xxxx xx xxx xxxxx xxxxxxxxxxx (xxx xxxxxxxxx xxxxxxxxxxxxxx) xx any xxxxx xxxxxxxxxx xxxxxxxx.

XXX. Xx xxx xxxxxxxxx xx x survivor xx a xxxxxx xxx has xxxx xx consequenee xx xxx xxxxxxxxxx xxxxxxxx xxx, xxxxxx xxxx xx xxx personal xxxx xx xxx xxxxxxxx:

1. Xxxxxxx:

2. Xxxxx xxxx:

3. Date of xxxxx:

4. Xxxx of xxxxx:

5. Last xxxxxxxxx xxxxxxx:

6. Xxxxxxxxxxx:

7. Xxxxxxxxxxxx xx xxx xxxxxxxx xx the xxxxxxxxx (x.x. father, daughter, xx xxxxxxxxxx living xx xxxxxx xxxxxxxxx)

Xx xxx xxxxxxxxx xx x xxxxxxxx xx x person xxx xxxx in xxxxxxxxxxx xx xxx xxxxxxxx xxx, xxxxxx xxxxxx x xxxx xx xxx xxxxx certificate xxx any xxxxxxxxx xxxxxxx xxxx xxx xxxxxxxx supported xx xxx xx obligation xx xxxxxxx xxx xxxxxxxx (in xxx xxxx xx a xxxxxx-xxxxx xxxxxxxxxxxx, such xxxxxxxxx xxxxxxx birth xxxxxxxxxxxx or x xxxxx xxxxxxxx on xxx obligation xx xxxxxxx xxx dependent; xx xxx xxxx xx xxxxxxx xxxxxxx, xxxxxx xxxxxx x xxxxxxxx xxxxxxxxxxx).

Xxxxxx specify the xxxx xx xxxxx xxx xxxxx xxx xxxxxxxxx xxx, xx xxx xxxxxx xxxxxxx xxxxx the consequences xx the crime xx a xxxxx xxxx, xxxxxx xxxx xxxxxxx xxx xxxx xxx xxx xxxxxx xx xxxxx xxx xxxxxx learned xx xxxx consequences (x.x., xxx xxxx xx xxx medical xxxxxx).

XX. Xxxxxx xxxxxxx the xxxxxxxx xxxxxxx authority (x.x. xxxxxx, xxxxxx xxxxxxxxxx'x xxxxxx, court) xxxxx xxxx xxxxxxxx xxxxxxxxx xxxxxxxx proceedings. Xxxxx xxx xxxxxxxxx xxxxxx xx xxx xxxx xxxxxxx to xxx xxxxxxxxxx proceedings.

If xxxxxxxxx, please attach xxx xxxxxx xxxxxxxx xx the xxxxxxxxxxxxxx xxxxxxxx xxxxxxx authority xxxxx could xxxxxxxx xxx xxxxx xx xxx respective proceedings (x.x. resolution xx xxx discontinuation xx xxxxxxxx xxxxxxxxxxx, xxxx xx xxx xxxxxxxxxx, xxxxxxxxx - xxxxx xx xxxxxxxxx).

According xx xxx xxxxxxxxxx xx §8 xx Xxx xx. 209/1997, xxx xxxxxx of xxxxxxxxx support xxx xx xxxxxxx xx xxxxxxxx depending xx xxxxxxx the xxxxxx xxx xxxx xxx xx xxx xxxxx xxxxxxxx to xxxxxxx x xxxxx xxx xxxxxxxxxxxx xxxxxxx xxx xxxxxxxx or xxx xxxxx person xxxxxxxxxxx xxx xxx harm xxxxxxxx. Xx not xxxx xx xxxx xxxx xx xxx xxxxxxxx xxx xxx xxxx identified.

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Fill in xxxx VlIl xx xxx xxxxxxxxx xx x xxxxxxxx xx xx individual xxx xxx died xx xxxxxxxxxxx xx xxx xxxxxxxxx xxxxx.

1. Xxx xxx x xxxxx, xxxxxx or xxxxx of xxx xxxxxx who xxxx xx xxxxxxxxxxx xx xxx criminal xxxxxxx?

2. Xxx xxx live xx a xxxxxx xxxxxxxxx xxxx xxx xxxxxxxx xxxxxx prior xx xxx xxxxxxxxxx xx the xxxxx?

3. Xxxx xxx x xxxxxxxxx xx xxx xxxxxx or xxx xxx xxxxxxxx xxxxxxx xx xxxxxxx xxx?

4. Xx xxx xxxxx xxxxxxx meet xxx xxxxxxxxxx xxxxxxxxx xx xxxxxxx 1 xx 3? Xxxxxx xxxx xxxxx number, if xxxxx xx xxx.

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Xxxxxxxxx xx xxx xxxxxxxxxx xx §2, section 2 xx Xxx xx. 209/1997, x xxxxxx who xx x xxxxxxxx of x xxxxxx xxx xxxx xx consequence xx a xxxxxxxx xxx is considered xx xx x xxxxxx xx xx xx she xx x xxxxxx, spouse xx xxxxx of xxx xxxxxxxx xxx xxxxx with him xx her xx xxx xxxx household xx xx the xxxxxx was x xxxxxxxxx of the xxxxxxxx xx xxx xxxxxxxx xxx required xx xxxxxxx xxx xxxxxx.

Xx xxx applicant xx the xxxxxx xx x xxxxx xxx xxx xxxxxxxx xxxxxx xxxx, please xxxx in items XX - XXX.

Xxxxxx xxxxxx x xxxxx-xxxxx assessment xx pain and xxxxxxxxx pursuant xx Xxxxxx Xx. 440/2001 Xxxx. The xxxxxxxxxx xxxxxxxx xxxxxx be xxxxxxxx xxxx xxx xxxxxxxxx responsible xxx xxx xxxxxx'x treatment. Xxxx medical xxxxxx xxxx xxxxxxx x xxxxx-xxxxx xxxxxxxxxx xx xxx pam xxxxxxxx xxx x point-based xxxxxxxxxx xx xxx xxxxxxxx xx the xxxxxx'x xxxxxx position. Xxxxxx xxxx in xxxx that xxxx xxx xxxxx-xxxxx xxxxxxxxxx xx the xxx xxxxxxxx xx xxxxxxxx xxx xxx xxxxxxxx xx Act no. 209/1997. Xxxxxxxxx xx xxx provisions of §6, xxxxxxx 2 xx Xxx no. 209/1997, no financial xxxxxxx xxxx be xxxxxxxx xxxxxx xxx xxxxx xxxxxxxxxx xx xxx pain suffered xx at least 100 xxxxxx.

Xxx xxxxxx may obtain xxxx sum financial xxxxxxx in xxx xxxxxx xx CZK 25,000 xx xx xxxxxx xxxxx xx xxx proved xxxxx xx xxxxxxx xxxxxxxxx xxx lost xxxxxx (§7, section 1, xxxxxx x xx Xxx No. 209/1997 Xxxx.). xx xxx xxxxxx xx xxxxx xxx x xxxx xxx payment, there xx xx need xx fill in xxxxx XII - XxX.

Xxxx includes xxx expenses xxx xxxxxxxxxx, sanitary xxxxxxxxx, xxxxxxxxxxxxxx xxxxx, xxxxxx xx xxxxxxxxx to xxxx xxx xx xxx xxxx xx xxxx xxxxxxx xxxxxxxxx, xxxxxxxxx transportation xxxxx xxx., provided such xxxxx xxxx xxx xxxx xxxx by xx insurance company. xx such xxxxxxxx xxx xxx xxxxxx xx xxxxxxxxxxx evidence, xxx Xxxxxxxx of Xxxxxxx xxx xxx xxxx xxxx xxxx xxxxxxxxxxxxx.

Please xxxxxx xxx xxxxxxxxx confirming xxxx xxxxx xx xxx application.

If xxx xxxxxxxxx xx xx xxxxxxxx, xxxxx xxxxxxxxx xxxxx include x xxxxxxxxx from his/her xxxxxxxx xxxxxxxxxx the xxxxxxx xxxxxx xxxxxxxxx xx §351 xx. xxx. of Xxx xx. 262/2006, xxx Xxxxx Xxxxxx Code, xx xxxxxxx. xx xxx applicant xx xxxx-xxxxxxxx, xxxx xxxxxxxx xxxxx be x xxxx xx xxx/xxx xxxx xxxxxx xxx xxxxxx. lf xxx xxxxxxxxx xx x xxxxxxx person xxx xx xxxx xx xxxxx his/her xxxxxxxx xxxxxx standing, xxxxxx xxxxxx x xxxxxxxx xxxxxxxxxx xxx xxxxxx xx xxx retirement xxxxxxx. xx for xxx reason the xxxxxxxxx'x xxxxxx situation xxxxxx be xxxxxx, xx exceptional cases xx affidavit may xx xxxxxxxx.

Xx xxxxxx xxxxxxxx has xxxx xxxxxxxx as x result xx xxx xxxxxxxx act xx xxxxx X xxx x victim. X have xxx xxx xxxx xxxxxxxxxxx xxx the harm 1 xxxx suffered xx x xxxxxx xx xxx criminal xxx.

X xxxxxx xxxxxx xxxx I have xxx lodged xxx xxxxx xxx xxxxxxxxx xxxxxxx or xxx xxxxxxx xxxxx for xxxxxxxxxxxx xxx the xxxx xxxxxxxx xx x xxxxxx xx xxx criminal xxx xx any xxxxxxx xxxxx xxxx xxx Xxxxx Xxxxxxxx.

X xxxxxxxxxxx xxxx according xx §12 of Xxx Xx. 209/1997 Xxxx., xx the xxxxxxxxx xx financial xxxxxxx xxx the xxxxxxx xx criminal acts xxx on amending xxxxxxx xxxxx acts, xx amended, X xx xxxxxxx to xxxxxxxxx xxx Ministry xx Justice xxx xxxxxx received as xxxxxxxxxxxx xxx the xxxx xxxxxxxx, xx xx the xxxxxx xx xxx xxxxxxxxx xxxxxxx, within five xxxxx xxxx xxx xxxx xx receiving xxx xxxxxxx xxxxxxx. X also acknowledge xxxx, after the xxxxx of the xxxx-xxxx xxxxxx, X xxx xxxx an xxxxxxxxxxx asking xxx Xxxxxxxx of Xxxxxxx xx waive xxx xxxxx'x claim for xxx return xx xxx xxxxxxxx xxxxxxx, xxxxxx xxxx x xxxxxx be xxxx xxxxxxxx xx xx xxxxxx xxxxxxxx, xxx xxxxx extent xx xxxx xxxxxxxx xxx xxx xxxxxx xx xxxxxxxxxxxx xxxxxxxx.

X xxxx xxxxxxxxxxx xxxx xxxxxxxxxxx xxxxxx false or xxxxxxxxxx xxxxxxxxxxx xx xxxxxxxxxxx xxxxxxxxxxx for xxx xxxxxxxx xx xxxxxxxxxxxxx gaining benefits xxx xxxxxxxxx xx xxxxxxx pursuant xx §21, xxxxxxx 1, xxxxxx x) of Xxx no. 200/1990 Xxxx., xx xxxxxxxx xx amended.

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Signature of xxx xxxxxxxxx xx xxx/xxx xxxxxxxxxxxxxx

- Xxxx xxxxxxx xx xxx xxxxxxxxxxx xxx the xxxxxxxxx xx financial xxxxxxx xxxxxxxx xx Xxx Xx. 209/1997, xxx Xxxxxxxx xx Xxxxxxx xxxxx confirm xxxxxxx xxx xxxxxx xx a serial xxxxxx. Subsequently, xxx Xxxxxxxx xxxxx xxxxxxxx xx xxxxxxxxxxxxx xxxx xxx xxxxxx xx x xxxxxxx xxxxxxxxx xx per xxx xxxxxxxx details of xxx case. Xxxxxx xxxxx months from xxx xxxx of xxx xxxxxxx xx xxx xxxxxxxxxxx and xxxxxxxxxx of xxx xxxxxxxxx xxxxxxxxx, the Xxxxxxxx xxxxx xxxxxx xxxxxxx the xxxxxxx xx inform the xxxxxxxxx xx the xxxxxxx xxx such xxxxxxx has been xxxxxxxx.

- Xxx xxxxxxxxx xxxxx xx xxxxxxxxxx x xxxxxx xx xxx Xxx Xx. 209/1997 Coll. only xx xx/xxx xxx xxxxxxxx bodily xxxx xx x xxxxxx xx the xxxxxxxxxx xx x xxxxx. X necessary xxx xxx the xxxx xxxxxxxxx xxx xxx xxxxxx'x receipt of xxxxxxxx xxxxxxx shall xx xxx amount xx the xxxxx-xxxxx xxxxxxxxxx xx xxx xxx suffercd (xxx xxx weakening of xxxxxx position), xxxxx xxxx be xx xxxxx 100 points. Xxxxxxxxx of a xxxxxx xxx xxx xxxx xx xxxxxxxxxxx xx x crime xxxxx xx xxxxxxxxxx xx xx x xxxxxx xx xxx xxxxxxxx xx x xxxxxx, spouse or xxxxx xx xxx xxxxxxxx xxx xxx xxxxxxxx shared a xxxxxxxxx with xxx xxxxxxxx xx the xxxx of his/her xxxxx or if xxx deceased xxxxxxxxx xx xxx xxxxxxxx xx support xxx xxxxxxxx.

- Xxx No. 209/1997 Coll. xx xxx xxxxxxxxx xx xxxxxxxxx xxxxxxx xx xxxxxxx of criminal xxxx xxxxxxxxxx a xxxxxxxxxx term xx 1 year xxxx xxx xxxx on xxxxx xxx victim xxxxxxx xx xxx xxxx caused xx xxx crime. Xx xxxx date xxxx xxx xxxxxxxx xxxx xxx xxxx xx xxx xxxxxxxxxx xx xxx crime, xxx xxxxxx xxxxx xxxxxxx xxxxxxxx xx xxx xxxx xx which xx/xxx learned of xxx consequences. Xxx Xxxxxxxx of Xxxxxxx xxxxxx meet xx xxxxxxxxxxx for xxx xxxxxxxxx xx xxxxxxxxx xxxxxxx xxxxxxxx xxxxxxx xxxxx the lapse xx xxx xxxxxxxxxxxxxx xxxxxx.

- Xxxxxxxxx support xx xxxxxxx xxx xx x xxxxxx xxx xxx xxxxxxxx xxxxxx xxxx xx x xxxxxx of xxx commitment xx x xxxxx may xx xx xxx xxxx of a xxxx xxx amounting xx XXX 25,000 xx an xxxxxx xxxxx to lost xxxxxx xx xxx xxxxx xx xxxxxxx xxxxxxxxx xx xxxxxx xx xxx victim, xxxxxxx xx xxx xxxxxx xxxxxxxxxx paid xx xxx xxxxxx xx xxxxxxxxxxxx for xxx harm incurred. Xxx xxxxx amount xx xxxx xxxxxxx xxxx not exceed XXX 150,000. Xx, xxxxx xxx xxxxxxxxx xx xxxxxxx, the xxxxxx proves xxxx xxx harm xxxxxxxx xxxxxxx the amount xxxxxxxx, xxx xxxxxx xxx xxxxxxx additional xxxxxxx xx to xxx xxxxxx of XXX 150,000 xx xx/xxx xxxxxxx xxx xx xxxxxx the xxxxxxxxxxxxxx xxxxxx xx xxxx (x.x., 1 xxxx from xxx xxxx on which xxx xxxxxx xxxxxxx xx xxx xxxx xxxxxx by xxx xxxxx); xx xxxx xxxx, xxx xxxxxxx xxxxxxx xxxx xxxx xx xxxxx xxxx xxxxxxx.

- Xx individual xxx xx x xxxxxxxx of x xxxxxx xxx has xxxx xx a xxxxxx of the xxxxxxxxxx xx x xxxxx (a xxxxxx, xxxxxx xx xxxxx xx xxx deceased xxxxxx xx x xxxxxx xxxxxxxxx xxxx xxx xxxxxxxx xx xxx xxxx xx xxx/xxx xxxxx xx xxxxxxxxx by xx xxxxxxxx to xx xxxxxxxxx xx xxx xxxxxxxx) xxxxx be xxxxxxxx xxxx x xxxx xxx xxxxxxxxx xx CZK 150,000. Xxx xxxxx xxxxxx xxxxxxxx xx financial xxxxxxx xxxxx not xxxxxx XXX 450,000; xxxxxx xxx xxxxxx xx xxxxxxx xxxxxx xxxxx, xxx xxxxxx xxxxxxxx per xxxxxx xxxxx xx xxxxxxx xxxxxxxxxxx.

- Xxx Xx. 209/1997 Xxxx. xxxx xxx replace the xxxxxxxxx xx xxx xxxxxxxxx xxxxxxxxx of xxxxxxxxx of motor xxxxxxxx related xx xxxxxxxxxx xxxxxxxxx xxxxxxxxx. Xx matters xxxxxxx xx traffic xxxxxxxxx, xxxxxxxxxxxx xxx insurance xxxxxxxx xxxxxx xxxx xx xxxxxxxx xx xxx xxxxxxxx xxxxxxxxx xxxx xxxxxxxxx insurance. Xxxx in isolated xxxxx, xx view xx xxxxxxxxxxx xxxxxxxxxxxxx, xxx an xxxxxxxxxxx xxx the provision xx xxxxxxxxx support xx xxxxx xxxx xxx Ministry xx Xxxxxxx.

- Xxxxxx xxxx xx xxxx that xxx xxxxxxxxx xxxxxxxxx xxx xxxxxxxxxxxxx xxxxxxxx xxx the xxxxxxxxxx xxxxx xxxx be xxxxxxxx to xxx xxxxxxxxxxx. If the xxxxxxxxx fails xx xx so, xxx Xxxxxxxx xx Xxxxxxx xxxxxx xxxxxxxx xxxxxxx xxx application. Should xxx xxxxxxxxx xxxx xx deliver xxx xxxx xxxxxxxxx xxx xxxxxxxxxxxxx xxxx xxxxxx x xxxxxxxxxxxxx xxxxxxxx, xxxx xxxx may xxxxxxx x xxxxxxxx xx xxxxxxxx any xxxxxxx xx per Xxx No. 209/1997 Xxxx. Xxxx xxxxx xxx, xxxxxxx, xxxxxxxxx xxx xxxxxx xx xxxxxxx xxxxxxxxxxx.

- Please xxxx in xxxx xxxx the xxxxxxxxx xxxxx xx xxxxxxx xx xxxxxx xxx xxxxxxxxx xxxxxx xxxxxxxx xx compensation for xxxx (xxxx xxx xxxxxxxx, xxxxxxxx xxx.) xx xxx account xx the Xxxxxxxx xx Justice up xx the amount xx xxx xxxxxxx xxxxxxxx. Xxxx xxxxxxxxxx xxxx not xxxxx xx he/she has xxx received xxx xxxxxxxxxxxx. If so xxxxxxxxx xx the xxxxxx xx xx xxxxxxxxxxx, xxx Xxxxxxxx xx Justice xxx xxxxx xxx xxxxx'x xxxxx to claim xxx return of xxx xxxxxxxxx xxxxxxx xxxxxxxx xxxxx xxx xxxxx xx xxx xxxx-xxxx xxxx, xxxxxxxx xxxx x xxxxxx xx justified xx xxx victim's xxxxxx xxxxxxxx, xxx total xxxxxx of the xxxx xxxxxxxx and xxx xxxxxx of xxxxxxxxxxxx xxxx to xxx xxxxxx.

Vážený xxx/xxxx/xxxxxx

Xxxxxxxxxxxxxxx xx, xx x xxxxxxxx, x ktorej xx xxxxxxxxxx, sme xxxxxx Vás obťažovať xxxxxxxxxxxx xxxxxxxx. X xxxxxx rýchleho xxxxxxxxx Xxxxx xxxxxxxx o xxxxxxxxxxx peňažnej xxxxxx xxxxxxx xxxxxxxx xxxxxxxx xxxľx zákona č. 209/1997 Zb., xx xxxx xxxxxxxxx xxxxx dotazníku xxxxxxxxxx. Xxxxxxxx Vám xx xxxxxxxxxx, xxxxx si xxxxx ceníme.

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I. Prosím, xxxxxxx čitateľne osobné xxxxx o xxxxxxxľxxx - obeti xxxxxxxxx xxxx, xxxxxx xxôxxxxxx xxxx na zdraví, xxxxx xxxxx xxxxxxxxxx xx osobe, xxxxx x dôsledku trestného xxxx xxxxxxx:

1. Xxxxxxxxxx:

2. Xxxx:

3. Xxxxx xxxxxxxxx:

4. Xxxxxx trvalého pobytu:

5. Xxxxxxxxxxxxxx adresa (v xxxxxxx, xx sa xxxx xx xxxxxx xxxxxxxx xxxxxxxx):

6. Xxxxxxx:

7. X-Xxxx:

8. Občianstvo:

II. Ak xxxxxxxľx xxxxxxxxx xxx xxxxx (zástupca) xx xxxxxxx xxxxxxxxx zastúpenia (xxxx. xxxxxxxx dieťa xxxxxx rodičom) xxxxx xx základe xxxxxx x xxxxx moci, xxxxxxx xxxxx x xxxxxxxxxx:

1. Priezvisko:

2. Xxxx:

3. Xxxxxxxxxxxxxx xxxxxx:

Xx žiadate xx xxx xxxxx, xxxx xx xxxxxxx xxxxxxxxxx, xxxxx zastúpenie xxxxxxx. Xxxxx x xxxxxxxx xxxxxxxx xxxxx xxxxx xxxx (pri xxxxxxxx xxxxxxxxx) xxxxx xxxxx rodného xxxxx (x xxxxxxx xxxxxxxxx xxxxxxxxxx) alebo inú xxxxxxx xxxxxxx.

XXX. Xx xxxxxxxľ alebo osoba xxxxxxxxx xx xxxxx, xxxxx v xôxxxxxx xxxxxxxxx činu xxxxxxx, xxxxxxx, xxxxxx, xx xxxxx x umretej xxxxx:

1. Xxxxxxxxxx:

2. Meno:

3. Xxxxx xxxxxxxxx:

4. Xxxxx xxxxxx:

5. Posledné xxxxxxxx:

7. Xxxxxxxxxx:

8. X xxxx xxxxxx bola xxxxxxx xxxxx x dôsledku xxxxxxxxx xxxx x xxxxx xxxxxxxľx (xxxx, xxxxx, xxxxx žijúca x xxxxxxxxx xxxxxxxxxx):

Xx xx xxxxxxxľ xxxxxx xxxxxxxxxx xx osobe, xxxxx x xôxxxxxx xxxxxxxxx xxxx zomrela, x žiadosti xx xxxx xxxxxxxx kópia xxxxxxxx xxxxx x xxxxxxx, xxxxx xxxxxxxxx xxxxxxxxxx, xx umretá xxxxx vyživovala xxxxxxxxx xxxxx xxxxx xxxx xxxxxxxxx xx vyživovať (xx xxxxxx rodič - xxxxx xôxxx x rodný xxxx xxxxx rozhodnutie xxxx x vyživovacej xxxxxxxxxx, xxx xxxxxxxx takou xxxxxxxx xxxx sobášny xxxx a xxx.)

XX. Xxxxxx, xx žiadate xxxxxxxx xxxxxxx xxxxx xxxxxxxxxxxxxxx xxxxx alebo xxxxxxxx xx xxxxxxx xxxx; x takom xxxxxxx láskavo xxxxxxx xxxxx Xxxxx xxxx.

X. Xxxxxx dátum, kedy xx obeť dozvedela x xxxxx spôsobenej xxxxxxxx činom.

Uveďte xxxxx xxxxxxxxx trestného xxxx x xx xx xxxx x škode xxx xxôxxxxxxx dozvedela xx xxxxôx, uveďte xxxx x ako (xxxxxxxxx z lekárskej xxxxxx - xxxxx xxx vystavenia).

VI. Xxxxxxx xxxxx činný v xxxxxxxx konaní (policajný xxxxx, xxxxxx xxxxxxxxxxxxxx, xxx), xxxxx xxxxxxxxx xxxxx xxxxxxx x xxxxxxxx čine. Uveďte xx xxxxxxx značku, xxx xxxxxx prebieha xxxxxxxxxxxx.

Xx xxxx x xxxxxxxxxx xxxxxxxx rozhodnutie xxxxxx xxxxxxx v xxxxxxxx xxxxxx, xxxxx xxxx xxxxxxxxx x xxx, x akom xxxxxx sa xxx xxxxxxxx (napr. xxxxxxxxx x odložení xxxxxxxxx xxxxxxxx, xxxx obžaloby, xxxxxxxx - x xxxxxxxxxxxxx), pripojte xx x xxxxxxxx.

XXX. Uveďte, xxxx xxôxxxxx ste xxxxxxxxx nárok na xxxxxxx škody xx xxxxxxxľx xxxxx xxxx xxxxx, ktorá xxxxxxxxx xx škodu.

Podľa ustanovenia §8 zákona x. 209/1997 (Zb)., xxxxxxxx xxxxx xx môže xxxxxx xxxxx xx xxxxxxxx s xxxxxxxxxxxxx xx xx, xx xxxx využila xxxxxx xxxxxxx xxxxxxxxxxx na xxxxxxxxxx nároku na xxxxxxx škody od xxxxxxxľx xxxxx inej xxxxx, xxxxx xxxxxxxxx xx xxxxx. Xxxxx xxx xxxxxxxxxxx, ak xxxxxxxľx trestného činu xxxxxxxxx.

Xxx XXXX. Vyplňte, xx xxxxxxxľ xx xxxxxxxxxx xx xxxxx, xxxxx x xôxxxxxx xxxxxxxxx xxxx xxxxxxx.

XXXX. Xxxxxx, či xxx xxxxxxx xxxxxx, ktorá xxľxx xxxxxxxxx uvedené x §2 odst. 2 xxxxxx x. 209/1997 Xx., prípadne xxľxx xxôx xxľxx xxxxx xxxxxxxxx, ak xx Xxx xxxxx xxxxxxxxxxx xxxxx.

1. Xxxx xxx xxxxxxx, xxxxxxxx xxxxx dieťaťom xxxxx, xxxxx zomrela x xôxxxxxx trestného xxxx?

2. Xxxx xxx x xxxxxx xxxxxxxxx xxxx xxxx xxxxxxxxx xxxxxxxxx xxxx v xxxxxxxxx xxxxxxxxxx?

3. Poskytovala Vám xxxx xxxxxxxxx xxxx xxxxxx, xx xxxx x xxxx xxxxxxx?

4. Xxľxxxx xxxxx xxxxx xxxxxxxxxxx xxxxxxxxx 1 xx 3? Xxxxxx xxx xxxxx, xx Xxx xx známy.

Podľa xxxxxxxxxxx §2 odst. 2 xxxxxx x. 209/1997 Zb. sa xx xxxx xxxxxxxx xxxxx xxxxxxxxx xx xxxxx, xxxxx x xôxxxxxx xxxxxxxxx činu xxxxxxx, xx je xxxxxxx, manželom xxxxx xxxxxxxx xxxxxxxxx a xxxxxxx x čase xxxx smrti x xxx žila x xxxxxxxxxx xxxxx osoba, xxxxxx xxxxxx poskytoval xxxxx bol xxxxxxx xxxxxxxxxx xxxxxx.

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Xxxx IX. xx XIV. Vyplňte, xx xx xxxxxxxľ xxxx xxxxxx xxxxxxxxx xxxx a bola xx xxôxxxxxx ujma xx xxxxxx.

XX. Xxxxxx xxxxx, xxxx sa xxxxxxxx xxxxxxxx, xxxxxxxxxx xxxx xx skončila xxxxxxxx xxxxxxxxxxx.

X. Xxxxxxx xxxxx xxxxxxxx xxxxxxxxxxx xx xxxxxx xxxx:

X xxxxxxxx xx musí xxxxxxxx xxxxxx ohodnotenie xx xxxxxx xxxľx xxxxxxxx č. 440/2001 Zb., ktoré xxxxxxxľ získa od xxxxxx, ktorý xx xxxxxxxxx. Xxxxx lekársky xxxxxxx bude xxxxxxxxx xxxxxx xxxxxxxxxx vytrpenej xxxxxxx x xxxxxx xxxxxxxxxx xxxxxxxx xxxxxxxxxxxxx xxxxxxxxxx. Xxxxxxxxxxx, xx xxx xxxxx xxxxxx č. 209/1997 Zb. je relevantné xxx bodové ohodnotenie xxxxxxxxx bolesti. Podľa xxxxxxxxxxx §6 odst. 2 xxxxxx x. 209/1997 Zb. nemožno xxxxxxxxx' peňažnú xxxxx, xx bodové xxxxxxxxxxx xxxxxxxxx xxxxxxx xxxxxxxxxx xxxxxxxx 100 xxxxx.

XX. Xxxxxx, xx xxxxxxx x poskytnutie peňažnej xxxxxx xx xxxxx xxxxxxxxx xxxxxxx 25&xxxx;000.- Xx alebo či xxxxxxxx xxxxx ušlého xxxxxxx x nákladov xx xxxxxxxx.

Xxxľx xxxxxxxxxxx §7 xxxx. 1 xxxx. a) xxxxxx x. 209/1997 Zb. xx xxxxxxx obete xxxxx xxxxxxxxx peňažnú xxxxx xx xxxxx xxxxxxxxx xxxx 25&xxxx;000.- Xx, xxxxx vo xxxxx zodpovedajúcej xxxxxxxxxxx xxxxxxxx xx xxxxxxxx x ušlému zárobku. Xx xx rozhodnete xxxxxx x xxxxxxx xxxxx xx xxxxx xxxxxxxxx čiastky, xxxxxxxx xx xxxxxxxxx xxxx XXX. - XIV. xxxxx xxxxxxxxx.

XXX. Náklady xxxxxxx x xxxxxxxx xxxxxx:

Xxx x xxxxxxx xx lieky, zdravotnícke xxxôxxx, xxxxxxx xx xxxxxxxxxxxxx, xxxxxxxxx cudzej xxxxx xx pomoc x domácnosti či xxxxxxxxxx, xxxxxxx xxxxxxx xx xxxxxxx, x xxx. pod podmienkou, xx tieto náklady xxxxxxxxx pojsťovňa. Xx xxxxxxx náklady xx xxxxx xxxxxxx, xxxx xx xx xxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxx mócť xxxx xxxxxľ.

XXXX. Popište xxxxxxxxx xxxxxx xxxxxxxľx xxxx x xx xxxxxx ujmy xx xxxxxx spôsobenej trestným xxxxx.

X xxxxxxxx xxxxxxxx xxxxxxx, xxxxx xxxxxxxxxx xxxxxxx xxxxxxxxxxx.

X xxxxxxx, xx xxxxxxxľ xx x xxxxxxxxxxxxxx xxxxxx, xôxxx x xxxxxxxxxx xxxxxxxxxxxxľx o priemernom xxxxxxx xxxľx §351 x xxxx. xxxxxx x. 262/2006 Zb., xxxxxxxx práce, x xxxxx xxxxxxxxxx predpisov. Xx xx žiadateľ xxxxxx samostatne xxxxxxxxx xxxxxx, xxxxx xxxxxxxx xxxx xxxxxxxxx xxxx xxxxxxxxxx xxxxxxxx xxxxxxxxx. Xx xxxxxxxľ xxxxxx xxxxxxxx xôxxxxxx, dokladom, xxxxx xôxx xxxxxxx xxxxxxxx sociálnu xxxxxxxx, xxxx xxxxxxxxxx x xxxxx xxxxxxxxxx dôchodku. X prípade, že x nejakého závažného xôxxxx xxxxxxx xxxxxxx xxxxxxxxx xxxxxx xxxxxxxľx, x xxxxxxx xxxxxxx xx možné xxxxxxxx xxxxxxxxxx o xxxx xxxxxxx xxxxxxxxxx.

XXX. Xxxxxx xxxxx xxxxxxxxxxxx dávok (xxxxxxxxxxx xôxxxxxx) x xxxx, xxxxxx ich xxxxxxxľ xxxxxx, či xxxxxxx po xxxxxx xxxx xx zdraví, xxôxxxxxxx xxxxxxxx xxxxx.

X xxxxxxxx xxxxxxxx xxxxxxxxxx xxxxxxxxxxxxľx xxxxx xxxxxxxxx x xxxxx xxxxxxxxxxxx xxxxx. V prípade, xx x xôxxxxxx xxxxx xx zdraví xxôxxxxxxx xxxxxxxx xxxxx Xxx priznali xxxxxxxxx xôxxxxxx, xxxxxx x xxxxxxx xxxx xxxxx.

Xxxx majetkové xxxxxx xx xxxx, že xxxxxxxx xxxxx, ktorého xxx xxx(x) xxxxxx, xx xxxx xxxxxxxx xxxxxxxx zhoršila. Xxxxx, xxxxx xx takto xxôxxxxx, xxxxxľ xxxxxx xxxxxxxx.

Xxxxxx vyhlasujem, že xxxxx xx xxxxxxx xxxxx či obdobný xxxxx xx xxxxxxxxxxx xxxx spôsobenej xxxxxxxx xxxxx som xxxxxxxxxx(x) x žiadnom xxxx xxxxx ako v Xxxxxx (Xxxxxxxxxx) xxxxxxxxx.

Xxxxxx xx vedomie, že xx xxxľx ust. §12 zákona x. 209/1997 Xx., o xxxxxxxxxx peňažnej xxxxxx xxxxxxx xxxxxxxx xxxxxxxx x o xxxxx x o doplnení xxxxxxxxxx xxxxxxx, v xxxxx neskorších predpisov, xxxxxx xxxxxxxxx xx xxxxxxx rokov xxx xxx, xxx mi xxxxxxxx pomoc, xxxxxxx xx xxxx Xxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxx, xxxxx xxx xxxxxx(x) xxx xxxxxxx xxxxx, x xx až xx xxxxx poskytnutej xxxxxx. Xxxxxxx s tým xxxxxx xx vedomie, xx xx uplynutí xxxxxxxxxx xäxxxxxxx doby xôxxx xxxxxxxx Ministerstvo xxxxxxxxxxxxxx, xxx xx x xxxx xxxxx xxxxxx xxxxx xx xxxxxxxx xxxxxxxxxxx xxxxxx, xx xxxx xxxxxxxx xxxxxxxx xxxx xxxx xxxxxx odôvodňovať, xxxxxxx xxxxx xxxxx, xxxxx xx xxôxxxxxx a xxxxx xxxxxxx, xxxxx xxx xxxxxx(x).

Xxxxxx xxxx xx vedomie, že xxxxxxxxx xxxxxxxx nesprávneho xxxxx neúplného xxxxx xx jeho xxxxxxxxx xx xxxxxx získania xxxxxxxxxxxx xxxxxx, xx xôxxx xxxxxxxx xxxxxxxxxx xxxľx §21 xxxx. 1 xxxx. x) xxxxxx x. 200/1990 Xx., x xxxxxxxxxxxx, x xxxxx xxxxxxxxxx xxxxxxxxx.

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xxxxxx xxxxxxxľx xxxxx xxxxxxxx

- Ministerstvo xxxxxxxxxxxxxx Xxxxx xxxxxxxxx xx xxxxxxx žiadosti x xxxxxxxxxxx xxxxxxxx pomoci xxxľx zákona č. 209/1997 Zb. xxxxxxx xxx xxxxxx x udelí poradové xxxxx. Xxxxx bude xxxxxxxxxx xx xxxxxxx xx xx inom xxxxxxxx xxxxxx xxxľx xxxxxxxxxxx xxxxxxxxx prípadu. Xx xxxxx xxxxxxxx xx podaní xxxxxxxx x xxxxxxxxxx potrebných xxxxxxxx xxx xxxxx xxxxxxxx alebo xxxxxxxľxxx xxxxxx dôvody, xxxxx xxxxx xxxxxxx xxxxxxxx.

- X xxxxxx xxxxxx č. 209/1997 Zb. bude xxxxxxxľ xxxxxxxxxx xx obeť xxx v xxxxxxx, xx mu x xôxxxxxx trestného xxxx xxxx xxôxxxxxx xxxxxxxxxx xxxxxxx. Nevyhnutnou, xxx xxxx xxxxxxxxxxxx xxxxxxxxxx xx priznanie peňažnej xxxxxx xxxxx obeti xx výška xxxxxxxx xxxxxxxxxxx bolesti (xxx xxxx xxxxxxxx xxxxxxxxxxxxx xxxxxxxxxx) dosahujúceho xxxxx 100 xxxxx. Xx xxxx sa xxxxxxxx xx osoba pozostalá xx xxxxx, xxxxx x xôxxxxxx trestného xxxx xxxxxxx, xx xxxx xxxxxxx, xxxxxxxx xxxxx dieťaťom xxxxxxxxx x zároveň v xxxx xxxx smrti x xxx xxxx x xxxxxxxxxx, xxxxx xxxxx, xxxxxx xxxxxxx xxxxxxxxxx alebo xxx xxxxxxx xxxxxxxxxx výživu.

- Xxxxx č. 209/1997 Zb. x xxxxxxxxxx xxxxxxxxx xxxxxx xxxxxxx trestnej xxxxxxxx xxxxxxxxx xxxxxxxxxxx (xxxxxxxx) xxxx 1 roka xxx dňa, xxx xx xxxx xxxxxxxxx x škode xxôxxxxxxx xxxxxxxx xxxxx. Ak xxxxx xxxx xx xxx je xxx xxxxxxxxx xxxxxxxxx xxxx, xxxx xxxxxxxx xxxxxxx, xxxx xx xx xxxxx. Xxxxxxxxxxxx xxxxxxxxxxxxxx xxxôxx xxxxxxxx xxxxxxxxxx x poskytnutie xxxxxxxx xxxxxx, xxxxx xx xxxxxxxx po uplynutí xxxxxxxxxx lehoty.

- Xxxxx xx na xxxxxxx xxxxx, ktorej x xôxxxxxx xxxxxxxxx činu xxxxxxx xxxxx na xxxxxx, poskytne x xxxxxxxxx sume 25&xxxx;000.- Xx alebo vo xxxxx, xxxxx xxxxxxxxxxx xxxxxxxxxx xxxxxx xx xxxxxxx, preukázané náklady xxxxxxx s liečením, xxxxxxx x súčet xxxxxxxx xxxxxxx, xxxxx xxxx x titulu xxxxxxx škody už xxxxxxx; pomoc xx xxxxxx xxxxx xxxxxx xxxxxxxxxx sumu 150 000.- Xx. Xx xxxx - xx xxx, xxx jej xxxxxxxx xxxxx - xxxxxxxx, xx xxx xxxxxxxxx xxxxx xx xxxxxx xxx xx, xxxxx xxxx podkladom xx xxxxxxxxxxx xxxxxx, na xxx žiadosť x xxxxxx stanovenej týmto xxxxxxx jej xxxxx xxxxxxxxx xxxxx opäť, x xx až xx xxxxxxxxxx výšky 150&xxxx;000.- Xx; pričom xx xxxxxxxxxx xx xxxxxxx, ktoré už xxxx vyplatené.

- Xxxxxxxx xxxxx, xxxxx je xxxxxxxxxx xx obeti, xxxxx v xôxxxxxx xxxxxxxxx xxxx zomrela (xx xxxx rodičom, xxxxxxxx xxxxx xxxxxxxx xxxxxxxxx x zároveň x xxxx xxxx xxxxx x xxx xxxx x domácnosti, xxxxx xxx xxxxxxx xxxxxxxxxx, xx xxx xxxxxxx xxxxxxxxxx xxxxxx), xx poskytne xxxxxxx xxxxx v paušálnej xxxx 150 000.- Kč; xxxxx xx svojom xxxxx nesmie xxxxxxxxxx xxxx 450&xxxx;000.- Kč, x ak xx xxxxx xxxxx xxxx xxx xxx xxxxx, xxxxxxxxxxx xxxxxxx sa xxx xxxxxx xxxxx xxxxxxxxx xxxxx.

- Xxxxx č. 209/1997 Zb. xxxxxxxxxxxx xxxxxxxx xxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxľx xxxxxxxxxx vozidiel, xx xxxxx nadväzuje povinné xxxxxxx xxxxxxxxx xxxxxxxxxxxxx. Xxxxx xx xxxxxxxx x xxxxxxxxxxxxxx dopravných xxxôx xxxxxx xxxxxxx, xxxxx xxxxxxxx xxxxxxxxx xxxxxxxxxxxxx, o poskytnutie xxxxxxxxx plnenia. Xxx x celkom ojedinelých xxxxxxxxx s prihliadnutím xx xxxxxxxxx xxxxxxxxx xxxxxxxxx xx xxxxx xxxxxx ministerstvo xxxxxxxxxxxxxx x xxxxxxxxxxx xxxxxxxx xxxxxx.

- Xxxxxxxxxxx, že xx xxxxxxxxxx xxxxxxxx xxxxxx xxxxxxxx xxxxxxx x xxxxxxxxxx, xx xxxxx xxxxxxxxxx pri xxxxxxxxxxxx xxxxxxxxx. Xx xxx žiadateľ xxxxxxx, xxxxxxxxxxxx xxxxxxxxxxxxxx nemôže xxxxxxx žiadosť. Ak xxxxxx xxxxxxxxxx a xxxxxxx ani xxxxxxxxx xxxxxx, xxxx xxxxxxxxxx xôxx xxx dôvodom xxxxxxxxxxxxx xxxxxxxx xxxxxx xxxľx xxxxxx č. 209/1997 Zb. Xx však xxxxxxxxxx xxxxxxx podať novú xxxxxxx.

- Xxxxxxxxxxxx, že xx bude žiadateľovi xxxxxxxxxx xxxxxxx xxxxx, xxxxxxxľ je xx xxxxxxx xxxxx xxx xxx poskytnutia pomoci xxxxxxx xx účet xxxxxxxxxxxx xxxxxxxxxxxxxx xxxx, xxxxx xxxxxx xxx xxxxxxx škody (od xxxxxxxľx, xxxxxxxxx x xxx.) xx do xxxxx xxxxxxxxxxx xxxxxx. Xxxx povinnosť xxxx, xx mu škodu xxxxxxxxxx. Xx základe xxxxxxxx obete xx xxxxxxxxxxxx xxxxxxxxxxxxxx môže x mene štátu xx uplynutí xxxxxxxxxx xäxxxxxxx doby xxxxx xxxxx xx xxxxxxxx xxxxxxxxxxx peňažnej xxxxxx. Xx takýto xxxxxx xxôxxxxxxx sociálna xxxxxxxx xxxxx, xxxxxxx xxxxx xxxxx, xxxxx xxx xxôxxxxxx, a xxxxx xxxxxxx, ktorú xxxx xxxxxxx.